Estate Planning Checklist PERSONAL AND FAMILY INFORMATION 1) Full Legal Name _____________________________________________ 2) Social Security _________________________ Birth Date:________ No. 3) Home Address _____________________________________________ _____________________________________________ 4) Home Telephone _____________________________________________ No. 5) Business Address _____________________________________________ _____________________________________________ 6) Business _____________________________________________ Telephone No. 7) Any Existing Will? YES ___ NO ___ (If Yes, please forward a copy (not the original)) 8) Have you created any trusts? YES ___ NO ___ (If Yes, please forward a copy) 9) Are you the beneficiary of any trust? YES ___ NO ___ (If Yes, please forward a copy) If married, please complete Nos. 10-16 for spouse. 10) Spouse's Legal _____________________________________________ Name 11) Social Security _________________________ Birth Date: _______ No. 12) Home Address and Telephone Number if different from 3 and 4 above ________________________________________________________________ ________________________________________________________________ 13) Business Address _______________ Telephone #______ 14) Any existing Will? YES ___ NO ___ (If Yes, please forward a copy) 15) Have you created any trusts? YES ___ NO ___ (If Yes, please forward a copy) 16) Are you the beneficiary of a trust? YES ___ NO ___ (If Yes, please forward a copy) 17) Date and place of present marriage _____________________________ ________________________________________________________________ 18) Any existing Premarital Agreements? YES ___ NO ___ (If Yes, please forward a copy) 19) If any prior marriages, list dates, when terminated, and any continuing support obligations. ________________________________________________________________ ________________________________________________________________ 20) List children of present marriage: LEGAL NAME BIRTH DATE SEX MARITAL STATUS 21) List children of any prior marriage: LEGAL NAME BIRTH DATE SEX MARITAL STATUS 22) List Grandchildren: LEGAL NAME BIRTH DATE SEX MARITAL STATUS 23) List all other relatives to be included or mentioned in Will: LEGAL NAME BIRTH DATE SEX RELATIONSHIP MARITAL STATUS 24) Are you, your spouse and children citizens of the U.S.A.? YES ___ NO ___ 25) Does your spouse or any child have any physical, mental or emotional disability? YES ___ NO ___ 26) Are you and/or your spouse interested in having a "Health Care Power of Attorney" prepared, whereby you would appoint an agent to make decisions regarding medical treatment on your behalf in the event you were unable to do so (i.e., comatose or otherwise incompetent or deemed incapable of making decisions on your behalf)? YES ___ NO ___ UNDECIDED ___ 27) Are you and/or your spouse interested in having a "General Power of Attorney" prepared, whereby you would appoint an agent to handle your property and affairs in the event you were to become incompetent or disabled? YES ___ NO ___ UNDECIDED ___ LIST THE VALUE OF EACH ASSET IN THE COLUMN BELOW ACCORDING TO HOW TITLE TO SUCH ASSET IS HELD ASSETS HUSBAND WIFE JOINT Cash and Cash Equivalent--Checking Account Savings Account Certificates of Deposit Money Market Funds Marketable-Securities--list name of security and number of shares Bonds--list name and face amount of bond, due date, and interest rate Personal Residence--Fair market value Less: mortgage balance Real Estate--list address and then (1) fair market value (2) mortgage balance Insurance--list owner, company, face amount, insured, type and beneficiary (see Schedule "A" attached) Closely held business interest--List name of company and estimated fair market value (see Schedule "B" attached) Investments in Partnerships--List name, original cost and fair market value Collectibles--art, coins, stamps, etc. (list item and value) Jewelry, Furs, Autos and other personal effects Receivables--list name of debtor and balance due Qualified Retirement Plans--Interest in IRAKEOGH--Profi Sharing Plans-Pension Plans-(See Schedule "C" attached) Liabilities--(other than mortgages on real estate) Taxes Personal loss Accounts Payable Notes Payable List any contingent liabilities below: INFORMATION FOR PROPOSED DOCUMENTS Name and Address of Executor(s) __________________________________________________________________________ ________________________________________________________________________ Name and Address of Successor Executor(s) __________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Name and Address of Trustee(s) __________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Name and Address of Successor Trustee(s) __________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ If Children are under Age 18, Name and Address of Testamentary Guardian(s) __________________________________________________________________________ ________________________________________________________________________ Name and Address of Successor Testamentary Guardian(s) __________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please list those persons upon whom you depend for business or financial advice in the following categories: Name Address Telephone No. Accountant Trust Officer Insurance Financial Advisor Other (state capacity) SCHEDULE "A" LIFE INSURANCE Comp-Whole-Life Own-Benefi-Cash Annual Face Outstanding Insured any # or er ciary Value Premi-Amount Loans Term um SCHEDULE "B" NATURE AND VALUE OF CLOSELY HELD BUSINESS INTERESTS For each such interest, complete: Type of Interest: __Sole Owner __Partnership __C Corporation __S Corporation Percentage of Ownership: _______________________________________ Fair Market Value: _____________________________________________ Description of Product or Service: _____________________________ Is there a buy/sell agreement? ___Yes ___No If yes, is it funded? ___Yes ___No If yes, what type is it? ______ Redemption agreement (i.e., corporation to purchase stock of a disabled or deceased shareholder) ______ Cross-purchase agreement (i.e., remaining shareholders to purchase stock of a disabled or deceased shareholder) ______ Other (i.e., "hybrid" arrangement) SCHEDULE "C" QUALIFIED RETIREMENT PLANS Please list all qualified retirement benefits below: Account Balance Beneficiary Death Benefit IRA Account(s): Keough Plan(s): Profit Sharing Plan(s): Pension Plan(s):